VAWC Form #4 CTRL NO.

________

BARANGAY PROTECTION ORDER

NAME OF RESPONDENT: ____________________________________
ADDRESS: _________________________________________________

ORDER

_______________________applied for BPO on _______________________, under oath stating that:

___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________

After having heard the application and the witnesses and evidence, the undersigned
hereby issues this BPO ordering you to immediately cease and desist from causing or
threatening to cause physical harm to ___________________________________________
and/or her child/children namely:
_________________________ ___________________________

_________________________ ___________________________

_________________________ ___________________________

This BPO is effective 15 days from receipt.

VIOLATION OF THIS ORDER IS PUNISHABLE BY LAW

________________________
Punong Barangay
Signature Over Printed Name

Date Issued: ___________________

Copy received by: ____________________________

Signature Over Printed Name

Date received: _____________________

Served by: ________________________

Signature Over Printed Name
ATTESTATION

(In case the Punong Barangay is unavailable)

I hereby attest that Punong Barangay _______________________________ was unavailable to act

On application for Barangay Protection Order No. ________ filed by _______________________________
On __________________ at __________________ a.m/ p.m and issue such order.

_____________________
Barangay Kagawad
Signature Over Printed Name